Pharynx pptx - د. باسل

Pharynx

Dr. Basil M.N. Saeed
Assistant Professor
Department of Surgery
College of Medicine
Mosul University

Pharynx

Is a funnel-shaped fibromuscular tube,
10-12 cm in length in adults.
Extends from the base of the skull to the level of C6.
The pharynx is divided
anatomically into 3 parts; Nasopharynx
Oropharynx
Laryngopharynx
(( Hypopharynx))

Behind :

The Nose

The Mouth

The larynx

Nasopharynx

Oropharynx

Laryngopharynx
(Hypopharynx)
Seen from behind

Nasopharynx(( Postnasal Space))

This extends from the base of the skull to the hard palate.
At the junction of the roof and posterior wall lies a small mass of lymphoid tissue called adenoids (nasopharyngeal tonsil).
On the lateral wall, there are the openings of the Eustachian tubes.
Behind which are hollows called the fossa of Rosenmuller, which is the site of nasopharyngeal malignancy

-Communicates inferiorly with the oropharynx through the velo-pharyngeal sphincter

Oropharynx

Extends from the level of hard palate to the level of hyoid bone and opens anteriorly into the oral cavity. Behind the oral cavity (in front of 2nd&3rd Cervical vertebra)
The palatine tonsils are situated in it's lateral wall
Between the ant. and post tonsillar pillars.

From the soft palate

superiorly to tip of
epiglottis inferiorly

Communicates:
Anteriorly with
the oral cavity
Superiorly with the
nasopharynx
Inferiorly with
the hypopharynx

Hypopharynx

Behind the Larynx (in front of 3rd to 6th Cervical vertebra)

From the tip of epiglottis

superiorly to
the lower border
of cricoid cartilage
inferiorly

Communicates:
Anteriorly with the Larynx
Superiorly with the oropharynx
Inferiorly with the esophagus

The hypopharynx does not only

lie behind the larynx BUT also
Projects laterally on each side of the larynx and is formed of :
Postcricoid region
( behind the larynx)
Two pyriform fossae
(on each side of the larynx

Pharyngeal Wall Histology

Wall Histology
The pharyngeal wall consists of 4 layers:
1. Mucous membrane.
2. Pharyngobasilar fascia.
3. Muscle layer.
4. Buccopharyngeal fascia.

1- Mucus Membrane

The lining epithelium is stratified squamous except in the nasopharynx, where columnar epithelium is found.

2- Pharyngobasilar fascia

This fascia is strengthened posteriorly by a strong band called the median raphae.

3- Muscular Layer
I- Circular (outer): which consist of 3 constrictor muscles overlapping one another from below upwards.
1. Superior constrictor.
2. Middle constrictor.
3. Inferior constrictor.

• The inferior constrictor muscle is composed of 2 parts:
• a. Thyropharyngeus (oblique): arises from the thyroid cartilage.
• b. Cricopharyngeus (transverse): arises from the cricoid cartilage and passes transversely backwards forming the upper oesophageal sphincter.
• All the constrictor muscles are inserted posteriorly into the median pharyngeal raphae.

Functions

The constrictor muscles propel the bolus of food down into the esophagus
The Cricopharygeus (lower fibers of the inferior constrictor) act as a sphincter, preventing the entry of air into the esophagus between the acts of swallowing

Killian dehiscence: this is a potential gap between the fibers of the thyropharyngeus and cricopharyngeus. The mucous membrane may bulge between these two muscles when there is incoordination of the pharyngeal peristaltic waves.

Pharyngael Pouch

• II- Longitudinal (internal): these muscles elevate the larynx and shorten the pharynx during deglutition:
• 1. Stylopharyngeus.
• 2. Salpingopharyngeus.
• 3. Palatopharyngeus

Buccopharyngeal Fascia
This fascia is loosely attached posteriorly to the prevertebral fascia and laterally connected to the styloid process and to the carotid sheath

Subepithelial lymphoid tissue of the pharynx (Waldeyer's ring)

Is a collection of sub-epithelial lymphoid tissue around the entrance of the respiratory and alimentary tracts.

Waldeyer's ring is formed by

• 1. Nasopharyngeal tonsil (adenoid).
• 2. Tubal tonsils: lie behind the openings of the Eustachian tubes.
• 3. Palatine tonsils.
• 4. Lingual tonsils: which is embedded in the posterior 1/3 of the tongue.
• 5. Lateral pharyngeal bands behind the posterior tonsillar pillar.
• 6. Lymphoid nodules scattered on the posterior pharyngeal wall

Hypertrophy of the lymphoid tissue of Waldeyer's ring occurs in the earlier years of childhood.
Maximum bulk is obtained at the age of 3- 6 years, and in old age it atrophies

• Waldeyer's ring is characterized by:
• 1. Sub-epithelial lymphoid tissue.
• 2. Lack a definite capsule.
• 3. They have efferent lymph vessels, but no afferent vessels.
• 4. Function as one unit: when a member of it is removed, the others parts undergo compensatory hypertrophy.

Palatine Tonsils

Two masses of lymphoid tissue situated on each side of the oropharynx.
The medial surface is exposed in the pharynx and is pitted by a number of crypts.
The tonsil is related anteriorly and posteriorly to the palatoglossus and palatopharyngeus muscles.
Laterally the tonsil is enclosed by a dense fibrous capsule separating the tonsil from the superior constrictor muscle (tonsillar bed).
This capsule provide a convenient plane of separation of the tonsil during tonsillectomy

Palatine tonsil

The main supply is the tonsillar branch of the facial artery, and decsending palatine artery.
The venous drainage is to the paratonsillar vein which drains to the pharyngeal plexus, and the internal jugular vein.
Lymphatic Drainage
Deep cervical chain of lymph nodes.

Blood Supply of the Tonsil

Sensory Nerve Supply

Nasopharynx: Maxillary nerve, trigeminal
Oropharynx: Glossopharyngeal nerve, trigeminal
Laryngopharynx: vagus nerve, and glossopharyngeal.
Motor supply
All the muscles of pharynx, except the stylopharyngeus, are supplied by the pharyngeal plexus.
Pharyngeal branches of the IX and X nerves, and sympathetic fibers from the superior cervical ganglion.
The stylopharyngeus is supplied by the glossopharyngeal nerve

Nerve Supply of the Pharynx

This space lies behind the pharynx and extends from the base of the skull to the superior mediastinum.
The anterior wall is formed by the posterior pharyngeal wall and it's covering buccopharyngeal fascia.
The posterior wall is formed by the cervical vertebrae and their covering muscles and fascia.

Retropharyngeal Space (Space of Gillette)

Contents:
Retropharyngeal lymph nodes of Rouviere.
Usually disappear
spontaneously during the
3rd or 4th year of life.

This potential space lies lateral to the pharynx and connects posteriorly with the retropharyngeal space.
It extends from the base of the skull to the hyoid bone.
It's bounded medially by the superior constrictor muscle.
Laterally lies the medial pterygoid muscle, the mandible and the parotid gland.
It's posterior wall is the prevertebral muscles and fascia.
Parapharyngeal Space

1. Deep cervical lymphnodes.
2. The last 4 cranial nerves and the cervical sympathetic trunk.
3. Great vessels of the neck: carotid and internal jugular vein.

Parapharyngeal space

• 1. Food and air inlet.

• 2. Play an important role in speech through vocal resonance and articulation.
• 3.The protective function of Waldeyer's ring.
• 4. Deglutition: it's divided into 3 stages:
• a. Oral stage (voluntary).
• b. Pharyngeal stage (involuntary).
• c. Oesophageal stage (involuntary).
Physiology of the Pharynx

1- Sore throat (pain)

a. Inflammatory.
b. Neoplastic.
c. Neurological: IX neuralgia.
d. Blood dyscrasia: agranulocytosis and leukaemia.
2- Dysphagia: is difficulty in swallowing whereas odynophagia is painful swallowing.
Dysphagia: Intraluminal, Luminal , Extraluminal
3- Difficulty in breathing like stridor in Ludwig's angina.
4- Difficulty in speech: Paralysis of the soft palate(hypernasalily).
5- Neck mass Cervical lymphadenopathy

Symptoms of Pharyngeal Diseases

Examination

Nasopharynx: This can be done with postnasal mirror and tongue depressor (posterior rhinoscopy), and it can be thoroughly examined by rigid and flexible endoscopes.
Oropharynx: It is simple with tongue depressor; palpation may be needed for the tongue.
Hypopharynx: It can be done with the use of laryngeal mirror to examine the larynx too. It can be done thoroughly with the use of endoscope.
Neck examination: for cervical lymphadenopathy.
Other areas : ears are examined for secretory otitis media in cases of nasopharyngeal tumours.

Investigations of pharyngeal diseases

Radiography:
Plain films like lateral X-Ray of the skull, is needed in nasopharyngeal mass like adenoids, and can demonstrate bone erosion in cases of nasopharyngeal cancer.
Contrast films: barium swallow is needed in the diagnosis of pharyngeal pouch, esophageal web and hypopharyngeal mass.
CT scan
MRI scan.
Laboratory investigations:
CBC, ESR, serum iron and iron binding capacity, monospot test, serology for toxoplasma, brucella, CMV and HIV.
Biopsy for suspected lesions in the pharynx may be needed.

• Is an inflammation of the whole lining of the oral cavity.
• It could be:
• -Viral infection: Herpes simplex
• -Bacterial: Gingivitis.
• -Fungal: candidiasis (thrush).
• -Spirochaetes: Vincent's angina.
• -Miscellaneous: Aphthus, Behcets syndrome, pemphigus and pemphigoid.
Stomatitis

Recurrent oral ulceration of unknown aetiology:

viral, psychogenic, endocrinal and autoimmune.
Clinical picture
This ulcer is typically quite sensitive and painful, has a central necrotic base with a surrounding red circumference.
Two types:
The minor form, more common, 3-6 mm in size and multiple and heal within 7-10 days without leaving a scar.
The major form, 1-2 cm in size, less common, long lasting and heal with a scar.
Aphthus Ulcer

Treatment

Is symptomatic:
-Oral antiseptic: like chlorhexidine gurgle.
-Topical application of local analgesic like xylocaine.
-Topical steroids e.g. Kenalog in orabase.

It is a gingivitis producing ulceration and necrotic membrane.

It is called "Trench Mouth"
Aetiology
Infection : Spirochaete, Borrelia vincenti & an Anaerobic organism , Bacillus fusiformis.
Occurs in debilitated patients who have poor dental hygiene.
Fever, sore throat , tender LN.
Acute necrotizing gingivitis (Vincent's angina)

On examination

The lesions originate around the interdental papillae and gums and may spread to involve the tonsil and oropharyx. The ulcers are painful, associated with foeter (fishy odor), and covered by a slough.

Diagnosis

Swab for gram stain and culture.
Treatment
-Oral hygiene by mouth wash.
- Antibiotics like benzyl penicillin + metronidazole.

Acute cellulitis of the floor of the mouth and submandibular space secondary to soft tissue infection.
Infection within a closed fascial space, tension rises rapidly and laryngeal oedema may occur.
Aetiology
Root abscess of the lower premolar and molar teeth (80%).The most usual organisms are strepto. viridans and E. coli.
-Tonsillar infection.
-Submandibular sialadenitis
Ludwig's Angina

Clinical picture
The patient is ill, toxic > 38 oC with odynophagia and salivation.
On examination
Indurated and usually non-fluctuant swelling below the angle of the jaw.
The floor of the mouth becomes very oedematous with the tongue pushed upwards.

• Potential complications

• -Airway compromise due to laryngeal oedema.
• -Spread into the parapharyngeal and retropharyngeal spaces.
• -Septicaemia.
• -Aspiration pneumonia.

Treatment

-Early stages (early cellulitis): heavy antibiotics covering aerobes and anaerobes.
-Drainage: If the state progress and the swelling increases.
Curved incision 2 cm below the angle of the jaw.
-Endotracheal intubation and
tracheostomy may be required
if laryngeal oedema
supervenes.

Acute pharyngitis

Acute inflammation of the mucous membrane of the pharynx occurring primarily in winter months.
Aetiology
Viral in origin( mostly adenovirus and rhinovirus).
20 % are bacterial: mostly Pneumococci, Haemophilus influenza and group A beta-hemolytic streptococci (S. Pyogens).
30 % No pathogen is isolated.
Pharyngitis may be part of the clinical picture of measles, scarlet fever, infectious mononucleosis and typhoid fever.

Pharyngitis

Symptoms
-Sore throat, Chills, Pyrexia, Headache and Joint pain.
Sings
-Redness and injection the mucous membrane of the pharynx.
-Hypertrophic and proliferation of lymphoid tissue on the posterior pharyngeal wall with particular aggregates in the lateral pharyngeal bands.
- Oedema of uvula
-Tender and palpable cervical LN.

Treatment

-Symptomatic: bed rest, analgesics and fluid by mouth.
-Antibiotics: if bacterial infection is suspected.

Generalized inflammation of the mass of the tonsil, usually accompanied by a degree of inflammation of the pharynx.
Any age group, most frequently found in children.
Aetiology
Bacteria :group A B-haemolytic streptococcus, pneumococcus, staphylococcus& Haemophilus influenzae.
Viruses: rhinovirus, adenovirus &
enterovirus

Acute Tonsillitis

• Symptoms

• Onset: often sudden :
• -Sore throat & odynophagia.
• -Constitutional symptoms especially in children.
• -Referred otalgia and abdominal pain due to mesenteric adenitis.
• Examination
• - Furred tongue & halitosis.
• - Tonsils: enlarged red and swollen.
• -The crypts become filled with pus (follicular tonsillitis).
• - A patchy membrane on the surface of the tonsil (membranous tonsillitis).
• -Cervical tender lymphadenopathy jugulodigastric node.

Acute follicular tonsillitis

• Differential Diagnosis
• -Scarlet fever: Streptococcal infection erythrogenic toxin.
• Tongue has a strawberry appearance
• Cutaneous punctate erythema.
• -Glandular fever:
• -Agranulocytosis and leukaemia.
• -Acute diphtheria.
• -Vincent's angina.

Scarlet fever

• Complications

• local
• a. peritonsillar abscess(quinsy).
• b. Retropharyngeal abscess.
• c. Parapharyngeal abscess.
• d. Acute otitis media.through the Eustachian tube.
• General
• a. Rheumatic fever and glomerulonephritis which follow B- haemolytic streptococcal tonsillitis of Lancet group A.
• b. Subacute bacterial endocarditis.
• c. Septicaemia.

Treatment
1. Bed rest, good oral fluid intake.
2. Antipyretics and analgesics.
3. Antibiotics: Penicillin, Erythromycin in allergy to penicillin.
Lack of response may suggest the presence of B-lactamase producing organism or even an anaerobic one, in which augmentin and/or metronidazole will be the antibiotic of choice.

Peritonsillar Abscess( Quinsy)

Is a collection of pus between the fibrous capsule of the tonsil and the superior constrictor.
Usually unilateral, Adult males.
Complication of acute tonsillitis.

Clinical Picture

1. The patient looks ill, feverish with rigor .
2. Acute sore throat & referred otalgia, Odynophagia). This makes the saliva dribbles from the month.
3. Trismus: irritation of the pterygoid muscles .
4. Thick and muffled voice often called “hot potato
voice”.
Examination
1. The tonsil is congested and pushed medially with the soft palate bulging downward and forward.
The uvula may be pressed against the opposite tonsil.
2. Red and enlarged anterior tonsillar pillar.
3. Tender and enlarged cervical lymph nodes

Treatment

I. Medical : Effective in early peritonsillar cellulitis.
II. Surgical : when considerable swelling is present or in case of failure to medical treatment.
1. Incision of the abscess: this is undertaken at the point of maximum swelling of the soft palate. The classical site is at a point where an imaginary line through the base of the uvula is intersected by a perpendicular line from the junction of the anterior tonsillar pillar with the tongue.
The tonsils might be removed 6-8 weeks following quinsy.
2. Abscess tonsillectomy

Membranous Pharyngitis

• -Viral infection: infectious mononucleosis.
• -Bacterial: diphtheria and scarlet fever.
• -Fungal: candidiasis.
• -Spirochaetes: Vincent's angina.
• -Blood dyscrasia: agranulocytosis and leukaemia.

Infectious Mononucleosis
Is a systemic infection by Epestein Barr virus which spread by droplets transmission. It is a disease of young adults and characterized by an increase in atypical lymphocytes.
Clinical picture
-Anorexia and low grade fever.
-Sore throat associated with odynophagia.
-Pharyngeal congestion with superficial ulceration of the tonsils. Red spots may appear on the palate.
-Generalized lymphadenopathy.
-Spleenomegaly.

Investigation

1. CBP increase in atypical lymphocytes (mononuclear cells).
2. Positive Paul-Bunnell and monospot tests.
Treatment
Is non specific
1. Antipyretics & analgesics.
2. Antibiotics play no role in treatment and ampicillin is not given as it may cause skin rash.

Diphtheria

Is a specific infection by Corynebacterium diphtheriae which is disseminated by droplets.
Children are mostly affected with a mortality of 10%.
Clinical picture
The patient is severely ill, although the temperature seldom rises above 38 oC.
The disease is characterized by the appearance of a membrane on the tonsils, soft palate and posterior pharyngeal wall.

The disease may spread to affect the nasal cavities and nasopharynx.

The membrane is usually grey in colour, firmly attached to the mucosa and leaves a bleeding surface when it's removed.
-Tender and enlarged cervical lymph nodes.

• Investigation
• Swab for bacteriological examination including part of the membrane.
• Complications
• -Laryngeal obstruction and stridor  tracheostomy.
• -Myocarditis and neuritis.
• The exotoxin produced by the microorganism is toxic to the heart and nerves.
• Neuritis is in form of paralysis of soft palate and ocular muscles.

Chronic Tonsillitis

Usually follows acute or subacute attacks of tonsillitis.
More common in children between the age of 4-15 years.
There is a chronic inflammatory hypertrophy, usually associated with adenoid enlargement.

Clinical picture:

Persistent or recurrent sore throat.
Persistent cervical adenitis.
Marked tonsillar enlargement with congested anterior pillars.

Treatment is usually surgical( tonsillectomy ) if symptoms persist.

Tonsillectomy

Indications for tonsillectomy

1. Recurrent attacks of acute tonsillitis.
2. Peritonsillar abscess (quinsy).
3. Sleep apnea syndrome.
4. Tonsillectomy for biopsy purposes.
Others:
Diphtheria carriers.
Recurrent attacks of otitis media ??
Acute rheumatic fever and acute glomeluronephritis if streptococcus tonsillitis has been responsible for recurrence

Contraindications

1. Bleeding disorders or clotting problems.
2. Acutely inflamed tonsil and recent upper respiratory tract infection.
3. Epidemic of poliomyelitis: fatal bulbar paralysis
4. Cleft palate: tonsillectomy leads to scarring of the soft palate which affects repair and speech.

Postoperative care

• 1. Nursing of patient in tonsillectomy position.
• 2. Careful monitoring of vital signs.
• 3. Analgesia: paracetamol. NSAID should be avoided.
• 4. Encourage the patient to move the muscles of the throat by swallowing, talking and dinking: shedding of the slough from the tonsillar fossa allowing healing to take place.

Complications

1. Haemorrhage
a. Primary: Recent infection, previous quinsy or severe scarring. Excessive bleeding from both fossae :coagulation defect.
Blood transfusion may be necessary.
b. Reactionary haemorrhage, within 24 hours. Preparing blood and early return to the theatre.
c. Secondary: Occurs some 5-8 days after the operation. It's due to infection.
Readmission to the hospital and a course of antibiotics is ordered.

2. Trauma: Teeth are at risk during tonsillectomy. Insertion of the mouth gag can lead to dislocation of the TMJ.
3. Infection: Prolongation of the pyrexia is a sign of infection which if untreated may lead to secondary haemorrhage.
4. Otitis media: should be distinguished from referred otalgia.
5. Chest complications: URTI at the time of operation or due to inhalation of blood or broken tooth.

Chronic irreversible inflammation of the mucous membrane of the pharynx with hyperplasia of it's various elements.
The normal lymphoid tissue on the posterior pharyngeal wall undergo hypertrophy so called granular pharyngitis.
The strip of lymphoid tissue in the posterior tonsillar pillar may undergo an overgrowth forming the lateral pharyngeal band.
Chronic Pharyngitis

Aetiology

Usually obscure:
-Recurrent attacks of acute
pharyngitis.
-Persistant neighbourhood
infection as chronic sepsis in
the sinuses, teeth, and gums.
Bronchiactasis is said to be associated with chronic pharyngitis.
-Exogenous irritants such as tobacco, alcohol and industrial fumes.
-Endogenous irritants as gastroesophageal reflux.
-Allergic factors.

Clinical picture

1. Sorethroat , no constitutional symptoms and the condition persists for weeks or months.

2. Foreign body sensation in the throat and tendency to clear the throat, which results from postnasal drip bathing the posterior pharyngeal wall.

3. Tiring of voice (not hoarseness).

Examination
Simple (catarrhal) type: redness and congestion of the pharyngeal mucosa. The uvula may appear enlarged or elongated.
Hypertrophic (granular) type: small nodules are scattered on the posterior pharyngeal wall giving a granular appearance. The lateral pharyngeal bands may be prominent.

Treatment

• 1.Treat the cause:
• Sinusitis, allergy, and GERD.
• 2. Avoidance of irritants: smoking, alcohol, and food.
• 3. Reassurance by the exclusion of malignancy.
• 4. Soothing gargles.
• 5. Antibiotics in acute exacerbation and fever.

Adenoids

The adenoids lie between the roof and posterior wall of the nasopharynx.

Adenoids differ from tonsillar tissue in that it's bounded by no capsule, contains no crypts and covered by ciliated epithelium.
Hypertrophy of the nasopharyngeal tonsil, sufficient to produce symptoms, most commonly between 3-7 years of age.

Symptoms

A-Nasal
- Nasal obstruction, mouth breathing, snoring , in severe cases: OSA.
- Persistent nasal discharge & postnasal drip. The child may be described as " always having a cold".
- Nasal speech (rhinolalia clausa).

B- Aural

Recurrent attacks of otitis media and otitis media with effusion.